The Affordable Care Act of 2010 established a focused U.S. policy of moving to a value-based model by realigning payment around the population health objectives of delivering better care at lower costs. The Centers for Medicare and Medicaid Innovation (CMMI) have been instrumental in testing new alternative payment models, with commercial insurers, employer groups and other payers following suit. In a recent annual survey conducted by Numerof & Associates, in partnership with Dr. David Nash of the Jefferson College of Population Health, several clear examples of success, or barriers to success, highlight the critical role which provider engagement plays in an organization’s ability to manage cost and quality.
In my own experience as a management consultant working with clinically integrated networks, health systems, academic medical centers and their medical staff, or other organizations focused on population health management, no factor has been more predictive of the ability to achieve quality and cost management objectives than authentic provider engagement. The direct engagement and involvement of respected physicians and other clinical leaders is needed for a couple simple reasons. Physicians and clinicians tend to listen to each other; and when it comes to managing cost in health care, behavior change needs to occur at the point of care by the providers who make treatment decisions, enter clinical orders and requisition tests and diagnostic procedures.
The Numerof & Associates analysis provides some interesting insights regarding respondents’ assessment of their organization’s readiness to be accountable for cost and quality. 65 percent said their organization was better than average at managing quality at the physician level; contrasted with only 35 percent who said their organization was better than average at managing cost at an individual physician level. The authors suggest the lack of confidence in managing healthcare costs “likely reflects a continuing lack of institutional engagement with physicians to drive improvement in quality and cost effectiveness.”
Provider engagement in the governance, program design, and decision making associated with quality and cost control initiatives helps ensure clinically sound, evidence-based interventions and policies are established and thought through to ensure viability in the office or at the bedside. Translating program concepts into workflows, new referral patterns, and the utilization of specific resources or procedures requires buy-in and adoption across the provider community, often specialty by specialty. Such efforts stand a better chance of success when championed and overseen by trusted and respected clinical leaders. Key processes investigated by the survey such as establishing care paths, flagging variation, providing physicians with comparative cost and quality data, and linking physician compensation to management of cost and quality showed there has been virtually no movement on these processes since their initial survey in 2015.
Indeed, just 47 percent of respondents reported their organizations routinely identified physicians who were outliers in cost or quality, and even fewer (37 percent) had a process to address such variation when it came to light. Just 35 percent linked compensation to cost and quality performance for any clinicians.
This year has demonstrated the vulnerability of healthcare practice reliant upon a fee-for-service model as in-person care diminished, and elective procedures were delayed or canceled as a result of the COVID-19 pandemic. As healthcare organizations revisit their journey to population health objectives and a further shift to value-based payment, provider engagement at each step will be crucial to staying on path.